Including what is relevant in a case notes is most crucial in writing a letter because each case notes comes with a lot of irrelevant information. You score high based on this skill. Look at the case notes below and say if the following pieces of information are relevant or irrelevant:
OCCUPATIONAL ENGLISH TEST
WRITING SUB-TEST: Nursing
READING TIME: 5 MINUTES
WRITING TIME: 40 MINUTES
Read the case notes below and complete the writing task which follows.
You are a registered nurse in the Cardiology Unit at St Luke’s hospital, Adelaide. Ms. Kylie Weiss is a patient in your care.
Today’s date: 09/07/2017
Name: Ms. Kylie Weiss
Address: 8758, Pulteney Street, Adelaide, SA, 5000
Date of admission: 07/07/2017
BIBA (Brought in by ambulance)
2-hour history of intermittent discomfort jaw;
Heaviness in both forearms; constant discomfort.
IV access in ambulance, 10 mg IV Morphine on route, Aspirin 300 mg chewed, Glytrin spray x 3 ECG showing ST elevation.
Diagnosis: Myocardial Infarction
- Weight: 85 kilograms, Height: 170 cm – Overweight (BMI-29)
- Ex-smoker – (stopped 1994)
- Mild osteoarthritis
- Mild asthma – no exacerbations within last 5 years
- Dyslipidemia (not treated)
- Medications: NIL
- Occupation: Works as taxi driver, mixed shifts
- Dietary Habits: Eats fast food- fries, hamburgers, doughnuts, ice cream, non-drinker.
- Brother – Coronary artery bypass grafting (CABG) at 70 years
- Sister MI (Myocardial Infarction) at 60 years, Mother-angina
- Marital status: Married, with one daughter
- Husband – Peter Weiss, 67 years, retired, aged pensioner
- Emergency Angioplasty
- ST Segment elevation on ECG –
- Direct stenting to proximal LAD
- Echocardiogram – Ejection fraction 35%
- Pain/Discomfort – managed
- Fasting Bloods (Lipids, Diabetes, TnI (proteins troponin), CBC (complete blood count) Cholesterol levels) checked.
- Nil further pain / discomfort,
- Cardiac status stable
- Seemed confused re. diagnosis,
- Reality of near-death experience
- Educated re event, MI diagnosis and modifications to risk factors (Cholesterol, wt. loss)
- R/v by Physiotherapist – cardiac exercise program provided
- R/v by dietician – diet for weight loss & reduced cholesterol levels
- Concerned about being unable to manage home on her husband’s pension – S/W input required
09/07/2017 Preparing for discharge
- Atorvastatin 40 mg OD, Metoprolol 23.75 mg OD
- Cilazapril 0.5 mg OD, Aspirin 100 mg OD, Ticagrelor 90 mg BD
- Glytrin spray prn for chest pain
- Refer to Cardiac Rehabilitation Nurse Specialist…
- Compliance with risk factor management (wt. loss, low cholesterol diet), medications, re-education re MI and its management.
- No driving for 6 weeks.
Using the information given in the case notes, write a referral letter to Ms. Nina Gill, Cardiac Rehabilitation Nurse Specialist, Cardiac Rehabilitation Clinic, 41, Jones St, Adelaide outlining important information.
In your answer:
- Expand the relevant case notes
- into complete sentences.
- Do not use note form.
- Use correct letter format.
The body of the letter should be approximately 200 words.